ICU 1.pptyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

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1. INTRODUCTION TO ICU, ICU SETUP, AND
ORGANIZATION

2. Contents
•Roles and types of critical care unit
•Levels of care
•Admission criteria
•Common causes of admission
•Causes of admission in Ethiopia
•Transferring The ICU patient

3. Introduction
•Critical illness:
Is a condition where life cannot be sustained without
advanced therapeutic interventions
•Intensive care:
•Doing the best for critically ill patients with the resources
available

4. Intensive care unit (ICU)
•A hospital area in which an increased concentration of
specialty trained staff and equipments allow more
detailed and frequent intervention in seriously ill patients
•Growing specialty for complex care
•Extremely expensive with more outcome data
•Large teams with mixed skills

5. •The aim is to provide the best possible care in the hospital
by :
•Providing a high ratio of nurses to patients,
•Concentrating limited resources and skills in one area of
hospital,
• Reserving expensive drugs and therapies for these
patients and to ensure that such therapies are properly
administered so as to obtain maximum effectiveness

6. ICU
•ICUs have noted to show a significant variation (e.g.
US$1783 to US$78 4351)in the cost per patient
admission . These differences have been attributed to a
number of different factors:
• Advances in healthcare technology, which may
increase or decrease costs.
• ICUs are not of a standard size; they have different
staff/patient ratios and research/ training activities.
• Treatment options differ, thus influencing patient
selection and costs

7. Types of ICUs
•Mixed
•Medical
•Surgical
•Cardiothoracic
•Trauma
•Neuro
•Liver…..

8. Levels of ICU
•Level - 1 care: - Small district hospital
•Provides basic monitoring
•Patient can be regularly turned
•Infusion can be supervised
•NG tube feeding given &
•Intubated patients suctioned
 MV and invasive cardiac monitoring are not available

9. •Level - 2 care: - General hospital
•Provides MV and cardiac monitoring facilities in addition to
level-1 care
•Provides a high standard of general intensive care
including multi-system life support
•It has access to physiotherapy, pathology and radiological
facilities at all times
 It may not have all complex forms of therapy and
investigation

10. •Level - 3 care – Tertiary hospital
•Provides all aspects of intensive care
•Provides support of complex Ix & imaging,
hemodialysis, cardiac pacing and CT scanning
•Very expensive cares can be provided

11. •Three factors differentiate level 3 (ICU) care from other
levels of care:
I.A very high nurse to patient ratio,
II.availability of invasive monitoring, and
III.The use of mechanical and pharmacological life
sustaining therapies

12. Who to admit
•ICU is the most expensive specialty
•Who should be admitted to ICU?
•Anyone who could benefit!!!
•ICU should be available to anyone who has
reversible pathology and has a reasonable chance
of returning to an acceptable quality of life, is just as
appropriate and almost as specific a guideline
12

13. •Accurate admission and discharge criteria that could
reduce resource wastage on:
•Pts who are too sick to benefit from intensive care and
In those that are to well to show cost-benefit
•Therefore ICU provision should concentrate on those
most likely to benefit from the resource

14. •Factors to be considered when assessing
admission to ICU:
•Diagnosis
•Severity of illness
•Age
•Coexisting disease
•Physiological reserve
•Prognosis
•Availability of suitable treatment
•Response to treatment to date
•Recent cardiopulmonary arrest
•Anticipated quality of life
•The patient's wishes

15. Common reasons for ICU admission
•Surgical interventions
•Surgery is the most common cause
•Shock
•Septic
•Cardiogenic
•Hypovolumic

15

16. •Acute respiratory failure (ARF)
•Mild ARF can be treated with O2 and supportive methods
•Moderate to severe RF may need ICU admission for mechanical
support
•ARDS is the most severe form of ARF, MV is indicated
•When critically ill pts can’t breath without assistance, breath
support may be necessary
16

17. •Infections
•Can be a cause of admission or prolonged stay in ICU
•Pneumonia and bacteremia are most common infections after
admission to ICU
•Renal failure
•Mild/moderate RF can be treated with fluid and medications
•Severe RF may need dialysis
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18. •Neurological conditions
•Traumatic brain injury
•Stroke
•Infections
•Cerebral hypoxia
•MODS
•Can be a cause of admission or may develop after ICU admission
•Cardiac arrest
•Pts are usu admitted to ICU after having cardiac arrest
18

19. Causes of ICU admission in
Ethiopia
19

20. •The study was conducted in JUSH, ICU
•According to this study:
•Common causes for admission:
•Cardiovascular problems (30.4%)
•Surgical interventions (18.8%) and
•Respiratory tract infection (11.6%)
•Traumatic brain injury (7.2%)
•ICU mortality was 37.7% (26/69)
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21. 21

22. 22

23. •A retrospective study in Tikur Anbessa Hospital (1985-
2000)
•Acute infections = 30%
•Cardiovascular diseases = 20%
•Specific diagnosis:
•DKA = 10.7%
•Acute MI = 9.8%
•Severe and complicated malaria = 9.3%
•ICU morality = 32%
23

27. •A retrospective study conducted to describe admission
and outcome pattern of children
•170 admissions over 5 yrs
•Overall mortality = 40%
•Trauma is major cause of admission (34.7%)
•Head injury 69.5%
•Burn (15%)
•Poly trauma (15%)
•Post op (28.2%)
•Medical conditions (27.6%)

28. Causes of death in ICU
• A prospective cohort study was conducted in
3700 patients admitted to ICU between January
1, 1997, and December 31, 2003, Austria
28

29. •According to this study:
•ICU mortality was 9.5%
Main causes of mortality were
•Septic shock (53.3%)
•Sepsis (17.5%) and
•Infection (10.1%)
•Acute, refractory multiple organ dysfunction syndrome was
the most frequent cause of death in the ICU (47%)
29

30. TRANSFER OF THE CRITICALLY ILL
PATIENT

31. Types
PREHOSPITAL CAREPREHOSPITAL CARE
INTRAHOSPITAL TRANSFERINTRAHOSPITAL TRANSFER: WITHIN A HOSPITAL: WITHIN A HOSPITAL
TO/FROM ORTO/FROM OR
ED TO HDU/ICUED TO HDU/ICU
TO RADIOLOGY: CT/MRITO RADIOLOGY: CT/MRI
INTERHOSPITAL TRANSFEINTERHOSPITAL TRANSFERR: OUTSIDE A HOSPITAL: OUTSIDE A HOSPITAL
ROAD/AIR/AMBULANCEROAD/AIR/AMBULANCE

32. Interhospital transfers

33. what is the RISK?
DETERIORATIONDETERIORATION
LIMITED OR NO PHYSIOLOGICAL RESERVELIMITED OR NO PHYSIOLOGICAL RESERVE
ADVERSE PHYSIOLOGICAL RESPONSESADVERSE PHYSIOLOGICAL RESPONSES
DISLODGEMENT OF AIRWAY/LINES/DRAINS/MONITORSDISLODGEMENT OF AIRWAY/LINES/DRAINS/MONITORS
HOSTILE/ UNFAMILIAR ENVIRONMENTSHOSTILE/ UNFAMILIAR ENVIRONMENTS
LIMITED RESOURCESLIMITED RESOURCES
EQUIPMENT PROBLEMSEQUIPMENT PROBLEMS
FAILURE OF CONTINUITY OF CARE/POOR HANDOVERFAILURE OF CONTINUITY OF CARE/POOR HANDOVER
SHOULD NOT BE TRANSFERRED FOR NON URGENT IXSHOULD NOT BE TRANSFERRED FOR NON URGENT IX
HOWEVER, BENEFIT TO PATIENT MAY OUTWEIGH RISK OF HOWEVER, BENEFIT TO PATIENT MAY OUTWEIGH RISK OF
TRANSPORTTRANSPORT

34. What’s needed
METICULOUS PLANNING
RIGHT EQUIPMENT
APPROPRIATE STAFF AND SKILL SET

35. 70% RESULT IN ADVERSE EVENTS
1/3 EQUIPMENT RELATED
MANAGEMENT IS HOWEVER CHANGED IN 40-50% THUS JUSTIFYING THE RISK.

36. AUDIT of 1000 adult transfers
HYPOTENSION, 29%
DESATURATION, 5%
HYPOTENSION PLUS DESATURATION 7%
HYPOTENSION AND BRADYCARDIA 2%
ARRESTED ON ARRIVAL 2%
45% FOUND TO BE HYPOTHERMIC

37. How to start assessing?
CLINICAL REASSESSMENT ESPECIALLY WHEN PATIENT TRANSFERRED ON TO THE EQUIPMENT THAT WILL BE USED FOR TRANSPORTCLINICAL REASSESSMENT ESPECIALLY WHEN PATIENT TRANSFERRED ON TO THE EQUIPMENT THAT WILL BE USED FOR TRANSPORT
AIRWAY CHECK: CHECK AND SECURE,OPTIMISE VENTILATION AND OXYGENATION, SUCTIONAIRWAY CHECK: CHECK AND SECURE,OPTIMISE VENTILATION AND OXYGENATION, SUCTION
GOOD PATENT IV ACCESSGOOD PATENT IV ACCESS
SECURE, MEASURE AND EMPTY ANY DRAINAGE DEVICESSECURE, MEASURE AND EMPTY ANY DRAINAGE DEVICES
SEDATION AND ANALGESIC DRUGS ADDRESSED AND ORGANISE ADDITIONAL DRUGS FOR TRANSPORTSEDATION AND ANALGESIC DRUGS ADDRESSED AND ORGANISE ADDITIONAL DRUGS FOR TRANSPORT

38. minimum monitoring required…
MINIMUM FOR VENTILATED PATIENTS:MINIMUM FOR VENTILATED PATIENTS:
CONTINUOUS ETC02CONTINUOUS ETC02
CONTINUOUS SP02CONTINUOUS SP02
CONTINUOUS INVASIVE/NON INVASIVE BPCONTINUOUS INVASIVE/NON INVASIVE BP
3 LEAD ECG3 LEAD ECG
CONSIDER DEFIBRILLATOR/EXTERNAL PACING DEVICECONSIDER DEFIBRILLATOR/EXTERNAL PACING DEVICE
CONSIDER NECESSITY/EXCLUSION OF OTHER DEVICES(ICP/CVP/PAP)CONSIDER NECESSITY/EXCLUSION OF OTHER DEVICES(ICP/CVP/PAP)

39. what to prepare?
OXYGEN: HAVE YOU GOT ENOUGH?OXYGEN: HAVE YOU GOT ENOUGH?
AIRWAY: ET TUBES, ALTERNATIVES, ADJUNCTS, TIES, GUEDELS, MASKS, SUCTIONAIRWAY: ET TUBES, ALTERNATIVES, ADJUNCTS, TIES, GUEDELS, MASKS, SUCTION
BREATHING: VENTILATOR, WATER CIRCUITBREATHING: VENTILATOR, WATER CIRCUIT
CIRCULATION: EMERGENCY DRUGS/DEFIB ACCESS/PACINGCIRCULATION: EMERGENCY DRUGS/DEFIB ACCESS/PACING
DRUGS: SEDATIVES. ANALGESICS, PUMPSDRUGS: SEDATIVES. ANALGESICS, PUMPS
EQUIPMENT: MONITORS, BATTERIES, POWER CABLESEQUIPMENT: MONITORS, BATTERIES, POWER CABLES
FLUIDS/IV ACCESS: SECURE AND SPAREFLUIDS/IV ACCESS: SECURE AND SPARE

40. when you get there…HANDOver?
ESSENTIAL, THOROUGH AND WITH GOOD DOCUMENTATION
TOOLS: MIST/SOBAR
ENSURE PATIENT CONNECTED TO WARD VENTILATOR, TRANSFERRED SAFELY
TO BED AND CLEAR HANDOVER PERFORMED

41. SPecial circumstances
HEAD INJURY PATIENTS
MRI

42. HEAd injury patients
Often need initial baseline and sometimes frequent subsequent scanning
Movement, position changes and changes in pac02 can cause significant elevations of icp
Exacerbation of secondary injury through inadequate management of primary brain injury

43. MRI
Use of MRI as special diagnostic/prognostic tool is increasingUse of MRI as special diagnostic/prognostic tool is increasing
special considerations:special considerations:
Incompatibility of monitoringIncompatibility of monitoring
lack of anaesthesia machinelack of anaesthesia machine
MRI checklistMRI checklist
c/i: pacemakers, cerebral aneurysm clipsc/i: pacemakers, cerebral aneurysm clips

44. Transfer to the operating room
• Familiarise yourself with the transport equipment and
ensure it is functioning before leaving the ICU.
• If the patient is already ventilated, establish on the
transfer ventilator before leaving the ICU to ensure
adequate ventilation can be maintained.
•Modern transfer ventilators have a PEEP facility and the
more sophisticated machines can provide pressure
control ventilation with variable I:E ratios.
•Consider increasing the patient’s sedation for the transfer.

45. •The planning, transfer, and monitoring of a critically ill
patient on the ICU needing surgery can be challenging.
Physiological instability should be anticipated, detected,
and acted upon promptly and effectively. Senior
anaesthetists and surgeons must be involved.
Consent
•Informed consent is often impossible as the patient may
be sedated or comatose.
•Whilst the family is not able to give consent in law, the
reasons for surgery and risks should be discussed with
them whenever possible.

46. Preoperative assessment
• Routine aspects of the preoperative assessment (e.g.
history of previous anaesthetics, chronic medical
conditions, allergies) are just as relevant to the critically ill
patient as they are to the elective case.
• Assess the patient’s current condition from discussion
with critical care team and from information on the
observation and drug charts.
• Note the current fluid requirements and rate/concentration
of inotrope infusions; ensure that there is an adequate
supply of inotrope prepared for theatre; consider which
vasopressors may be required.

47. •If the patient is not already sedated and ventilated decide
whether to induce in ICU, the anaesthetic room, or
theatre:
•Factors influencing the decision will be safety, available
assistance, haemodynamic instability, and patient
comfort.
• Monitor the patient fully en-route.
• Disentangle all lines, re-establish full monitoring, and
check IV access before the start of surgery.

48. Transfer back to ICU
• Inform the ICU staff when surgery is about to finish; this
enables them to prepare to receive the patient and
possibly to assist in the transfer.
• Ensure that a full verbal and written handover is given to
the ICU medical and nursing staff and communicate the
postoperative requirements.

49. 49
Thank you !! Thank you !!